Provider Demographics
NPI:1811944192
Name:NEWCO AMBULATORY SURGERY CENTER, LLP
Entity type:Organization
Organization Name:NEWCO AMBULATORY SURGERY CENTER, LLP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CAROL LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:BURGETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-989-7751
Mailing Address - Street 1:4190 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3882
Mailing Address - Country:US
Mailing Address - Phone:810-989-7651
Mailing Address - Fax:
Practice Address - Street 1:4190 24TH AVE
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3882
Practice Address - Country:US
Practice Address - Phone:810-989-7651
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7238585OtherAETNA
MIDC4024Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MI0N97320Medicare ID - Type Unspecified